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Back Pain Office Hours Telephone Triage Protocols | Adult | 2017

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Back Pain Office Hours Telephone Triage Protocols | Adult | 2017 Back Pain Office Hours Telephone Triage Protocols | Adult | 2017 DEFINITION ⦁ Complains of upper, mid, or lower back pain that occurs mainly in the midline. ⦁ Not due to a traumatic injury ⦁ Minor muscle strain and overuse are covered in this guideline. Sciatic pain is also covered. PAIN SEVERITY is defined as: ⦁ MILD (1-3): doesn't interfere with normal activities ⦁ MODERATE (4-7): interferes with normal activities or awakens from sleep ⦁ SEVERE (8-10): excruciating pain, unable to do any normal activities Excluded: ⦁ Pain in the back from significant blunt or penetrating trauma should be triaged using the Back Injury guideline. ⦁ Pain in the lower back in pregnant women, consider labor. See Pregnancy - Labor and Pregnancy - Labor, Preterm guidelines. TRIAGE ASSESSMENT QUESTIONS Call EMS 911 Now Passed out (i.e., fainted, collapsed and was not responding) R/O: AAA FIRST AID: Lie down with feet elevated. Shock suspected (e.g., cold/pale/clammy skin, too weak to stand) R/O: AAA FIRST AID: Lie down with feet elevated. Sounds like a life-threatening emergency to the triager See More Appropriate Protocol Major injury to the back (e.g., MVA, fall > 10 feet or 3 meters, penetrating injury, etc.) Go to Protocol: Back Injury (Adult) Pain in the upper back over the ribs (rib cage) that radiates (travels) into the chest Go to Protocol: Chest Pain (Adult) Pain in the upper back over the ribs (rib cage) and worsened by coughing (or clearly increases with breathing) Go to Protocol: Chest Pain (Adult) Go to ED Now SEVERE abdominal pain (e.g., excruciating) Office Hours Telephone Triage Protocols | Adult | 2017 Page 1 Back Pain Abdominal pain and age > 60 R/O: compression fracture, aortic aneurysm Unable to urinate (or only a few drops) and bladder feels very full R/O: urinary retention, cauda equina syndrome Numbness (loss of sensation) in groin or rectal area Go to ED/UCC Now (or to Office with PCP Approval) Sudden onset of severe back pain and age > 60 R/O: compression fracture, aortic aneurysm Pain radiates into groin, scrotum R/O: kidney stones Blood in urine (red, pink, or tea-colored) Vomiting and pain over lower ribs of back (i.e., flank - kidney area) Weakness of a leg or foot (e.g., unable to bear weight, dragging foot) R/O: nerve root impingement or cord compression Patient sounds very sick or weak to the triager Reason: severe acute illness or serious complication suspected Go to Office Now SEVERE back pain Fever > 100.5° F (38.1° C) and flank pain R/O: pyelonephritis Pain or burning with urination R/O: pyelonephritis See Today in Office Can't walk or can barely walk R/O: severe back strain, cord compression Tingling or numbness in the legs or feet R/O: severe back strain, cord compression High-risk adult (e.g., history of cancer, history of HIV, or history of IV drug abuse) R/O: metastasis, epidural abscess Painful rash with multiple small blisters grouped together (i.e., dermatomal distribution or 'band' or 'stripe') R/O: herpes zoster (shingles) Pain radiates into the thigh or further down the leg, and in both legs Reason: bilateral sciatica carries higher risk Office Hours Telephone Triage Protocols | Adult | 2017 Page 2 Back Pain See Today or Tomorrow in Office Pain radiates into the thigh or further down the leg R/O: sciatica Age > 50 and no history of prior similar back pain Reason: higher risk of serious medical cause Patient wants to be seen See Within 2 Weeks in Office Back pain persists > 2 weeks Back pain is a chronic symptom (recurrent or ongoing AND lasting > 4 weeks) Home Care Back pain R/O: muscle strain, overuse Caused by a twisting, bending, or lifting injury R/O: muscle strain, overuse Caused by overuse from recent vigorous activity (e.g., exercise, gardening, lifting and carrying, sports) R/O: muscle strain, overuse Preventing back strain, questions about HOME CARE ADVICE Back Pain 1. Reassurance: ⦁ Twisting or heavy lifting can cause back pain. It can also occur after un-noticed minor back injuries ⦁ With treatment, the pain most often goes away in 1-2 weeks. ⦁ You can treat most back pain at home. ⦁ Here is some care advice that should help. 2. Cold or Heat: ⦁ Cold Pack: For pain or swelling, use a cold pack or ice wrapped in a wet cloth. Put it on the sore area for 20 minutes. Repeat 4 times on the first day, then as needed. ⦁ Heat Pack: If pain lasts over 2 days, apply heat to the sore area. Use a heat pack, heating pad, or warm wet washcloth. Do this for 10 minutes, then as needed. For widespread stiffness, take a hot bath or hot shower instead. Move the sore area under the warm water. 3. Sleep: ⦁ Sleep on your side with a pillow between your knees. If you sleep on your back, put a pillow under your knees. ⦁ Avoid sleeping on your stomach. ⦁ Your mattress should be firm. Avoid waterbeds. Office Hours Telephone Triage Protocols | Adult | 2017 Page 3 Back Pain 4. Activity: ⦁ Keep doing your day-to-day activities if it is not too painful. Staying active is better than resting. ⦁ Avoid anything that makes your pain worse. Avoid heavy lifting, twisting, and too much exercise until your back heals. ⦁ You do not need to stay in bed. 5. Pain Medicines: ⦁ For pain relief, you can take either acetaminophen, ibuprofen, or naproxen. ⦁ They are over-the-counter (OTC) pain drugs. You can buy them at the drugstore. Acetaminophen (e.g., Tylenol): ⦁ Regular Strength Tylenol: Take 650 mg (two 325 mg pills) by mouth every 4-6 hours as needed. Each Regular Strength Tylenol pill has 325 mg of acetaminophen. ⦁ Extra Strength Tylenol: Take 1,000 mg (two 500 mg pills) every 8 hours as needed. Each Extra Strength Tylenol pill has 500 mg of acetaminophen. ⦁ The most you should take each day is 3,000 mg (10 Regular Strength or 6 Extra Strength pills a day). Ibuprofen (e.g., Motrin, Advil): ⦁ Take 400 mg (two 200 mg pills) by mouth every 6 hours. ⦁ Another choice is to take 600 mg (three 200 mg pills) by mouth every 8 hours. ⦁ The most you should take each day is 1,200 mg (six 200 mg pills), unless your doctor has told you to take more. Naproxen (e.g., Aleve): ⦁ Take 220 mg (one 220 mg pill) by mouth every 8 hours as needed. You may take 440 mg (two 220 mg pills) for your first dose. ⦁ The most you should take each day is 660 mg (three 220 mg pills a day), unless your doctor has told you to take more. 6. Pain Medicines - Extra Notes: ⦁ Use the lowest amount of medicine that makes your pain better. ⦁ Acetaminophen is thought to be safer than ibuprofen or naproxen in people over 65 years old. Acetaminophen is in many OTC and prescription medicines. It might be in more than one medicine that you are taking. You need to be careful and not take an overdose. An acetaminophen overdose can hurt the liver. ⦁ McNeil, the company that makes Tylenol, has different dosage instructions for Tylenol in Canada and the United States. In Canada, the maximum recommended dose per day is 4,000 mg or twelve Regular-Strength (325 mg) pills. In the United States, McNeil recommends a maximum dose of ten Regular-Strength (325 mg) pills. ⦁ Caution: Do not take acetaminophen if you have liver disease. ⦁ Caution: Do not take ibuprofen or naproxen if you have stomach problems, kidney disease, are pregnant, or have been told by your doctor to avoid this type of anti-inflammatory drug. Do not take ibuprofen or naproxen for more than 7 days without consulting your doctor. ⦁ Before taking any medicine, read all the instructions on the package. 7. Call Back If: ⦁ Numbness or weakness occur ⦁ Bowel/bladder problems occur ⦁ Pain lasts for more than 2 weeks ⦁ You become worse Preventing Back Strain 1. Prevention: ⦁ The only way to prevent future backaches is to keep your back muscles in excellent physical Office Hours Telephone Triage Protocols | Adult | 2017 Page 4 Back Pain condition. ⦁ A sedentary lifestyle (lack of exercise) is a risk factor for developing back pain. ⦁ Walking, stationary biking, and swimming provide good aerobic conditioning as well as exercise for your back. ⦁ Being overweight puts more weight on the spine and thus increases the risk of back pain. If you are overweight, work with your doctor to develop a weight-loss program. 2. Good Body Mechanics: ⦁ Lifting: Stand close to the object to be lifted. Keep your back straight and lift by bending your legs. Ask for lifting help if needed. ⦁ Sleeping: Sleep on a firm mattress. ⦁ Sitting: Avoid sitting for long periods of time without a break. Avoid slouching. Place a pillow or towel behind your lower back for support. ⦁ Posture: Maintain good posture. 3. Strengthening Exercises: ⦁ During the first couple days after an injury, strengthening exercises should be avoided. The following exercises can help strengthen the back. Perform the following exercises 3-10 times each day, for 5-10 seconds each time. ⦁ Bent knee sit-ups: Lay on back, curl forward lifting shoulders about 6 inches (15 cm) off the floor. ⦁ Leg lifts: Lay on back, lift foot 6 inches (15 cm) off floor (one leg at a time). ⦁ Pelvic tilt: Lay on back with knees bent, push lower back against floor. ⦁ Chest lift: Lie face down on ground, place arms by your sides, lift shoulders off the floor. 4. Call Back If: ⦁ You have more questions ⦁ You become worse FIRST AID FIRST AID Advice for Shock: Lie down with the feet elevated.
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